Unobserved “Home” Induction Onto Buprenorphine

Abstract

There is insufficient evidence supporting unobserved induction as more, less, or as effective as observed induction. However, the predominantly observational and naturalistic studies of unobserved induction reviewed, all of which have significant sources of bias and limited external validity, document feasibility and low rates of adverse events. Unobserved induction seems to be widely adopted in US and French regional provider surveys. Prescribers, policy makers, and patients should balance the benefits of observed induction such as maximum clinical supervision with the ease-of-use and comparable safety profile of unobserved induction.

Management of opioid use disorders: a national clinical practice guideline

“…22 There is also potential for cost savings and greater patient autonomy with home induction of buprenorphine-naloxone, 34,35 which under appropriate circumstances, yields similar outcomes as office-based induction in terms of patient safety, retention and reductions in nonmedical opioid use. 33 However, buprenorphinenaloxone requires an individual to be in moderate withdrawal before induction to avoid precipitated withdrawal, which can present greater challenges than methadone inductions, making buprenorphine-naloxone less attractive in certain cases. 55 The relative ease of transition from buprenorphine-naloxone to methadone further supports the use of buprenorphinenaloxone as the preferred first-line treatment when appropriate.…”

“…• Health Canada exemption is not required to prescribe buprenorphine-naloxone in most provinces and territories (Appendix 1) • Lower risk of overdose due to partial agonist properties and ceiling effect for respiratory depression (in the absence of benzodiazepines or alcohol) 19,24,25 • Lower risk of public safety harms if diverted 26,27 • Milder adverse effect profile 22,23 • Easier to transition from buprenorphine-naloxone to methadone if treatment is unsuccessful 22,23 • Shorter time to achieve therapeutic dose (1-3 d) [28][29][30] • Lower risk of toxicity and drug-drug interactions 31 • Milder withdrawal symptoms when discontinuing treatment; may be a better option for individuals with lower-intensity opioid dependence (e.g., oral opioid dependence, infrequent or no injection use, short history of opioid use disorder), and individuals planning to taper off opioid agonist treatment in a relatively short period 22,23 • Optimal for rural and remote locations where access to care is limited, methadone prescribers are lacking, or daily witnessed ingestion at a pharmacy is not feasible • More flexible dosing schedules (e.g., alternate-day dosing, earlier provision of 1-to 2-week take-home prescriptions, and unobserved home inductions) support patient autonomy and can reduce costs [32][33][34][35] • Easier to adjust and retitrate following missed doses, owing to its partial agonist properties…”

Effects of a Higher-bioavailability Buprenorphine/Naloxone Sublingual Tablet Versus Buprenorphine/Naloxone Film for the Treatment of Opioid Dependence During Induction and Stabilization: A Multicenter, Randomized Trial

“…Similar reductions in treatment-retention rates were observed in both treatment arms in this subgroup. The challenge of buprenorphine induction among patients transitioning from methadone has been previously reported, 12,13,22 and further studies are needed for elucidating treatment protocols regarding induction in patients transitioning from the use of long-acting opioids such as methadone.…”

Clinical Case Conference

“…In brief and as reviewed elsewhere in this issue of Journal of Addiction Medicine, there is no evidence to date that either approach, observed or unobserved induction, is associated with superior safety, tolerability, retention, or opioid misuse outcomes (Lee, Vocci, Fiellin, 2014). The induction literature does point to several key patient and treatment characteristics as possibly predictive of difficult inductions but to date finds no difference between observed and unobserved methods.…”